1. CET Cancer Center Oakland California High Dose Rate (HDR) Brachytherapy Gynecological Cancer D. Jeffrey Demanes M.D jdemanes@cetcancercenter.com

2. Brachytherapy IntracavitaryInterstitial Low Dose RateHigh Dose Rate CET Radiation is given directly to target Gradient effect– relatively little dose to surrounding tissue

3. Robotic High Dose Rate (HDR) Brachytherapy Source position x Time = Effective Source Strength HDR is given in 1-2 sessions per day Radiation is confined to patient

4. Applicator Placement High Dose Rate Robotic Treatment 3 Dimensional Scan Imaging Virtual Image Computer Dosimetry CET A Four Step Process

5. Intracavitary Multi-Channel Vaginal Cylinder Decreases dose to bladder and rectum by 15% *IJROBP Vol. 44, No. 1, pp.211-219, 1999 Cylinder cross section

6. CET Intracavitary Tandem and Ovoids

7. Various Example Devices CET jdemanes@cetmc.com

8. HDR Interstitial Direct tissue access Catheter scaffolding ‘matrix’ Encompass extensive disease CET jdemanes@cetmc.com

9. CET

10. 2 Scan 3D Image with Implant

11. CET 3) Virtual Image of Implant

12. CET 3) Another Patient with CT Dosimetry

13. Recurrent Pelvic Sidewall Cervix Cancer

14. 3) Virtual Image viewed from above Left Pelvic Sidewall

15. 4) HDR Treatment Delivery

16. 4 HDR Treatment Delivery

17. CET Protocol Gynecologic Cancer External Beam Radiation Therapy Small TumorsLarge TumorsMetastatic 36 Gy39.6 Gy45-50 Gy 50.4 Gy minimum to pelvic lymph nodes HDR Brachytherapy 5.5 - 6.0 Gy 5-6 sessions (1 or 2 implants 1 week apart) CET

18. Dose Constraints Anterior rectum: 75 % Posterior bladder and urethra: 80% 3 Dimensional Dosimetry Normal Tissue Transluminal View Rectum CET

19. Applicator Selection. Intracavitary (T&O, Vaginal cylinders etc.) Small lesion, good response to EBRT, adequate anatomy If applicator fits Interstitial (Template etc.) Bulky disease, parametria or vaginal involvement Anatomy not suitable for intracavitary

20. Cervical Cancer Radiation and Chemotherapy Chemotherapy Cisplatinum weekly Not given during HDR Acute ChemoRadiation Toxicity Hypokalemia Dehydration Pancytopenia CET

21. Previously Untreated Cervix 5 Year Results 204 Pts 1991-1999 FIGO StagePathologyScan IB 1 36 (18%)Squam 82%Nx 4% IB 2 45 (22%)Adeno 12%N0 85% II2a 21 (10%)AdenoSq 6%N1 11 % II2b 59 (29%) IIIa 12 (6%)BT Method IC = 36% IS = 64% IIIb 24 (12%)Hysterectomies 14.5% IVa 7 (3%)Chemotherapy 16% jdemanes@cetmc.com Median age 55

22. 5 Year Results Cervix Cancer Local Control by Stage 0 10 20 30 40 50 60 70 80 90 100 Patient Group % 85% ALL IB1 1B2 IIA IIB IIIA IIIB IVA

23. Patient Group CET Cervix 5 Year Results Patient Group 0 10 20 30 40 50 60 70 80 90 100 % 85% Local Control Pelvic Control 81% DM 22% 66% DFS 60% OS jdemanes@cetmc.com CET

24. Chronic Morbidity Cervix SiteGrade 3Grade 4 Bladder32 Rectal51 Gyn50 Total Bladder and Rectal = 11/204 (5%) CET

25. Previously Untreated Vagina Cancer 8 Year Results 53 Patients 1991-2001 FIGOPathologyCT Scan I 11%Squamous 78%Nx 9% II 76%Adeno 20%N0 78 % III 11%AdenoSq 2%N1 13 % IVa 2%Chemotherapy 15% Intracavitary 15% Interstitial 85% jdemanes@cetmc.com Median age 64

26. Patient Group CET Vagina 5 Year Results Patient Group 0 10 20 30 40 50 60 70 80 90 100 % 87% Local Control Pelvic Control 83% DM 17% 62% DFS 52% OS jdemanes@cetmc.com CET

27. SiteGrade 3Grade 4 Bladder01 Rectal03 GYN40 Total Bladder and Rectal = 4/53 (7.5%) jdemanes@cetmc.com CET Chronic Morbidity Vagina Ca

28. . D. Jeffrey Demanes M.D jdemanes@cetcancercenter.com Thank You. CET Cancer Center